Respiratory dysfunction in degenerative cervical myelopathy: A systematic review

INTRODUCTION

Degenerative cervical myelopathy is a condition of symptomatic cervical spinal cord compression secondary to a range of degenerative spinal pathology. Respiratory symptoms such as shortness of breath are not uncommonly reported by people with DCM and respiratory dysfunction has been described in several DCM studies. The objective of this review was therefore to systematically synthesise the current evidence on the relationship between DCM and respiratory function.

METHODS

The review was registered on PROSPERO and adhered to PRISMA guidelines. Ovid MEDLINE and Embase were searched from inception to 14th March 2023. DCM studies reporting on any measure or outcome relating to respiratory function or disease were eligible. Reference lists of included studies and relevant reviews articles were hand searched. Title, abstract and full text screening, risk of bias and GRADE assessments were completed in duplicate. A quantitative synthesis is presented.

RESULTS

Of 1991 studies identified by literature searching, 13 met inclusion criteria: 3 cohort studies, 5 case-control studies, 1 case series and 4 case studies. Forced vital capacity (FVC), peak expiratory flow rate (PEFR) and maximal voluntary ventilation (MVV) were reported to be lower in DCM patients than controls; there was inconsistency in comparisons of forced expiratory volume in 1 s (FEV1). There was conflicting evidence on whether surgical decompression was associated with improvements in respiratory parameters and on the relationship between level of spinal cord compression and respiratory dysfunction.

CONCLUSION

DCM may be associated with respiratory dysfunction. However, consistency and quality of evidence is currently low. Further work should characterise respiratory dysfunction in DCM patients more rigorously and investigate putative mechanisms such as disruption to cervical nerve roots responsible for diaphragmatic innervation and damage to descending spinal projections from brainstem respiratory centres.

Recurrent Acute Disseminated Encephalomyelitis Presenting as Conus Medullaris Syndrome: A Case Report

Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disorder that typically follows an infection or recent vaccination. Symptoms such as encephalopathy and focal neurological deficits appear weeks after the initial illness, leading to swift and progressive neurological decline. While ADEM in the brain has been well documented, reports of ADEM, specifically in the spinal cord, are relatively limited. A 58-year-old male presented with rapidly progressive bilateral lower extremity tingling, numbness, and mild gait disturbance approximately two days prior to visiting the emergency room. Spinal magnetic resonance imaging revealed a diffuse, longitudinal, high-signal lesion with mild enlargement of the conus and proximal cauda equina. The lesions were predominantly localized in the distal conus and cauda equina, and serial electrodiagnostic studies showed that the lesions progressed toward the proximal conus in tandem with symptom evolution and lacked clear lateralization. The patient was subsequently treated with high-dose steroids for seven days (intravenous methylprednisolone, 1 mg/kg). The patient's lower extremity weakness gradually improved and he was able to walk independently under supervision three weeks after symptom onset. In this case of spinal ADEM in a middle-aged adult, high-dose steroid treatment led to outstanding neurological recovery from both the initial occurrence and subsequent attacks.

End-of-life walking ability in cancer patients with spinal metastases

BACKGROUND

Even terminal cancer patients desire to walk to the toilet by themselves until the very last day. This study aimed to describe the walking ability of patients with spinal metastases at the end-of-life stage and identify the factors affecting this ability.

METHODS

Among 527 patients who first visited our multidisciplinary team for bone metastasis between 2013 and 2016, 56 patients who had spinal metastases with a Spinal Instability Neoplastic Score ≥7 and died during follow-up were included. We collected general clinical data, performance status, Frankel classification, epidural spinal cord compression scale and Spinal Instability Neoplastic Score at the first consultation. Patients' last day of walking and date of death were also examined. Univariate analyses (chi-squared tests) were performed to identify the factors that impacted walking ability 30 and 14 days before patients' death.

RESULTS

A total of 56 patients were extracted, and 57.1% (32/56) and 32.7% (16/49) of patients were ambulatory 30 and 14 days before death, respectively. Their performance status (P = 0.0007), Frankel grade (P = 0.012) and epidural spinal cord compression grade (P = 0.006) at the first examination, and administration of bone modifying agents during follow-up period (P = 0.029) were significantly related to walking ability 30 days before death. Among ambulatory patients 30 days before death, those with Spinal Instability Neoplastic Score ≥10 (P = 0.005), especially with high scores of collapse (P = 0.002) and alignment (P = 0.002), were less likely to walk 14 days before death. The walking period in the last month of their life was significantly longer in patients with total Spinal Instability Neoplastic Score 7-9 (P = 0.009) and in patients without collapse (P = 0.040) by the Wilcoxon test.

CONCLUSION

The progression of spinal metastasis, especially neurological deficit, at the initial consultation were associated with walking ability 30 days before death, and spinal stability might be crucial for preserving walking ability during the last month. Early diagnosis and implementation of appropriate bone management might be important for the end-of-life walking ability.

Subclinical respiratory dysfunction and impaired ventilatory adaptation in degenerative cervical myelopathy

Degenerative cervical myelopathy (DCM) is a debilitating neurological condition characterized by chronic compression of the cervical spinal cord leading to impaired upper and lower limb function. Despite damage to areas of the cervical spinal cord that house the respiratory network, respiratory dysfunction is not a common symptom of DCM. However, DCM may be associated with respiratory dysfunction, and this can affect the ventilatory response to respiratory challenges during emergence from anesthesia, exercise, or pulmonary disease. Surgical spinal cord decompression, which is the primary treatment for DCM, leads to improved sensorimotor function in DCM; yet its impact on respiratory function is unknown. Here, using a clinically relevant model of DCM, we evaluate respiratory function during disease progression and assess adaptive ventilation to hypercapnic challenge before and after surgical intervention. We show that despite significant and progressive forelimb and locomotor deficits, there was no significant decline in eupneic ventilation from the early to late phases of spinal cord compression. Additionally, for the first time, we demonstrate that despite normal ventilation under resting conditions, DCM impairs acute adaptive ventilatory ability in response to hypercapnia. Remarkably, akin to DCM patients, surgical decompression treatment improved sensorimotor function in a subset of mice. In contrast, none of the mice that underwent surgical decompression recovered their ability to respond to hypercapnic ventilatory challenge. These findings underscore the impact of chronic spinal cord compression on respiratory function, highlighting the challenges associated with ventilatory response to respiratory challenges in individuals with DCM. This research highlights the impact of cervical spinal cord compression on respiratory dysfunction in DCM, as well as the persistence of adaptive ventilatory dysfunction after surgical spinal cord decompression. These results indicate the need for additional interventions to enhance recovery of respiratory function after surgery for DCM.

Cervical syringomyelia with caudal thoracic epidural lipomatosis: case report and literature review

Syringomyelia associated with epidural lipomatosis is a rare finding. Only three published cases of epidural lipomatosis associated with syringomyelia exist in the literature. We report the case of a 46-year-old woman who presented with progressive myelopathy over an 18-month period. Imaging revealed significant thoracic spinal cord compression secondary to epidural lipomatosis from T3 to T8 with cephalad cervical syringomyelia extending from C7 to T1. Imaging was unremarkable for Chiari malformation or a craniospinal space-occupying lesion. A T2 to T8 laminoplasty was performed, removing excessive epidural adipose tissue to decompress the thoracic spinal cord. Postoperatively, the patient reported symptom improvement with complete symptom resolution at 3 months. Follow-up imaging at 3-months demonstrated thoracic spinal cord decompression with mild syrinx reduction. At two-year follow-up the patient remained asymptomatic with unchanged imaging. Syringomyelia in the setting epidural lipomatosis is a rare finding.

Is the type and/or co-existence of degenerative spinal pathology associated with the occurrence of degenerative cervical myelopathy? A single centre retrospective analysis of individuals with MRI defined cervical cord compression

BACKGROUND

Degenerative cervical myelopathy (DCM) arises from spinal degenerative changes injuring the cervical spinal cord. Most cord compression is incidental, referred to as asymptomatic spinal cord compression (ASCC). How and why ASCC differs from DCM is poorly understood. In this paper, we study a local cohort to identify specific types and groups of degenerative pathology more likely associated with DCM than ASCC.

METHODS

This study was a retrospective cohort analysis (IRB Approval ID: PRN10455). The frequency of degenerative findings between those with ASCC and DCM patients were compared using network analysis, hierarchical clustering, and comparison to existing literature to identify potential subgroups in a local cohort (N = 155) with MRI-defined cervical spinal cord compression. Quantitative measures of spinal cord compression (MSCC and MCC) were used to confirm their relevance.

RESULTS

ELF (8.7 %, 95 % CI 3.8-13.6 % vs 35.7 %, 95 % CI 27.4-44.0 %) Congenital Stenosis (3.9 %, 95 % CI 0.6-7.3 % vs 25.0 %, 95 % CI 17.5-32.5 %), and OPLL (0.0 %, 95 % CI 0.0-0.0 % vs 3.6 %, 95 % CI 0.3-6.8 %) were more likely in patients with DCM. Comparative network analysis indicated loss of lordosis was associated with ASCC, whilst ELF with DCM. Hierarchical Cluster Analysis indicated four sub-groups: multi-level disc disease with ELF, single-level disc disease without loss of lordosis and OPLL with DCM, and single-level disc disease with loss of lordosis with ASCC. Quantitative measures of cord compression were higher in groups associated with DCM, but similar in patients with single-level disc disease and loss of lordosis.

CONCLUSIONS

This study identified four subgroups based on degenerative pathology requiring further investigation.

Acute ptotic myelopathy: cervical compressive myelopathy resulting from prolonged head ptosis after alcohol intoxication

A 28-year-old man was brought to the emergency department with quadriparesis of acute onset after a bout of binge drinking. Evaluation revealed a mid-cervical myelopathy and magnetic resonance imaging (MRI) showed an acute compressive cervical myelopathy. He also developed rhabdomyolysis, and cervical paraspinal muscles showed MRI hyperintensities. After resolution of rhabdomyolysis and acute kidney injury, he underwent cervical spine fixation. He was found to have acute dropped head syndrome with secondary compressive myelopathy.

C1-C2 subluxation in enthesitis-related arthritis: two case reports and literature review of ten cases

BACKGROUND

C1-C2 subluxation is a rare complication of enthesitis-related arthritis (ERA). If left untreated, it may lead to functional impairment or cervical spinal cord compression. This study aims to highlight key points regarding the management of C1-C2 subluxation in ERA.

CASE PRESENTATION

We present two cases of C1-C2 subluxation: an 8-year-old boy with ERA and 16-year-old boy with ERA with bilateral sacroiliitis. Ten cases of ERA in the literature were reviewed. The diagnosis of C1-C2 subluxation is mostly based on radiographs and cervical spine computed tomography. All patients were treated with non-steroidal anti-inflammatory drugs. Six ERA patients were treated surgically for cervical fusion. Most ERA patients with sacroiliitis had cervical collar protection. Neurologic abnormalities after treatment were not reported. Despite the use of cervical collar, cervical fusion and persisting ankylosis were found in two ERA patients with sacroiliitis without surgical treatment.

CONCLUSIONS

Cervical spine protection and ruling out spinal cord compression should be prioritized, in addition to controlling the underlying inflammation in ERA. Cervical halter traction may be applied after severe cervical inflammation is excluded. To reduce the risk of complications, early recognition and appropriate treatments of C1-C2 subluxation in ERA are essential.

Transmandibular Cervical Corpectomy for Persistent Spinal Cord Compression in a Patient With Klippel-Feil Syndrome: A Technical Note and Systematic Review

BACKGROUND

Few studies have described a transmandibular approach for decompression in a patient with Klippel-Feil syndrome (KFS) for cervical myelopathy.

OBJECTIVE

To describe the transmandibular approach in a KFS patient with cervical myelopathy and to perform a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

METHODS

A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Embase and PubMed databases were searched from January 2002 to November 2022 for articles examining patients with KFS undergoing cervical decompression and/or fusion for cervical myelopathy and/or radiculopathy were included. Articles describing compression due to nonbony causes, lumbar/sacral surgery, nonhuman studies, or symptoms only from basilar invagination/impression were excluded. Data collected were sex, median age, Samartzis type, surgical approach, and postoperative complications.

RESULTS

A total of 27 studies were included, with 80 total patients. Thirty-three patients were female, and the median age ranged from 9 to 75 years. Forty-nine patients, 16 patients, and 13 patients were classified as Samartzis Types I, II, and III, respectively. Forty-five patients, 21 patients, and 6 patients underwent an anterior, posterior, and combined approach, respectively. Five postoperative complications were reported. One article reported a transmandibular approach for access to the cervical spine.

CONCLUSION

Patients with KFS are at risk of developing cervical myelopathy. Although KFS manifests heterogeneously and may be treated through a variety of approaches, some manifestations of KFS may preclude traditional approaches for decompression. Surgical exposure through the anterior mandible may prove an option for cervical decompression in patients with KFS.

Prognostic MRI parameters in acute traumatic cervical spinal cord injury

PURPOSE

The aim of this study is to estimate the prognostic value of some features documented on preoperative MRI study in patients with acute cervical spinal cord injury.

METHODS

The study was conducted in patients operated for cervical spinal cord injury (cSCI) from April 2014 to October 2020. The quantitative analysis on preoperative MRI scans included: length of the spinal cord intramedullary lesion (IMLL the canal diameter at the level of maximal spinal cord compression (MSCC) and the presence of intramedullary hemorrhage. The canal diameter at the MSCC was measured on the middle sagittal FSE-T2W images at the maximum level of injury. The America Spinal Injury Association (ASIA) motor score was used for neurological assessment at hospital admission. At 12-month follow-up all patients were examined with the SCIM questionnaire.

RESULTS

At linear regression analysis, the length of the spinal cord lesion [β coefficient -10.35, 95% confidence interval (CI)-13.71 to-6.99; p < 0.001], the diameter of the canal at the level of the MSCC (β coefficient 6.99, 95% CI 0.65 to 13.33; p = 0.032), and the intramedullary hemorrhage (β coefficient  - 20.76, 95% CI - 38.70 to - 2.82; p = 0.025), were significantly associated with the score at the SCIM questionnaire at one year follow-up: shorter spinal cord lesion, greater diameter of the canal at the level of the MSCC, and absence of intramedullary hemorrhage were predictors of better outcome.

CONCLUSION

According to the findings of our study, the spinal length lesion, canal diameter at the level of spinal cord compression and intramedullary hematoma documented by the preoperative MRI study were associated with the prognosis of patients with cSCI.

The Utility of COMPASS-31 Questionnaire to Predict Autonomic Dysfunction in Patients With Cervical/Upper Thoracic Compressive Myelopathy

BACKGROUND

Patients with cervical/upper thoracic compressive myelopathy may have autonomic dysfunction. The composite autonomic severity score (CASS) is the gold standard test to detect autonomic dysfunction, and the self-rated composite autonomic system scale (COMPASS-31) questionnaire is a screening tool to diagnose autonomic dysfunction. This study compared the COMPASS-31 and modified CASS scores for the detection of autonomic dysfunction in patients with compressive myelopathy.

METHODS

Patients with cervical/upper thoracic compressive myelopathy scheduled for decompressive surgery completed a COMPASS-31 questionnaire and underwent autonomic function tests to calculate the modified CASS score before surgery.

RESULTS

Forty-two patients were included in the study; 19 (45.2%) had mild autonomic dysfunction, 5 (11.9%) had moderate autonomic dysfunction, and 18 (42.9%) had severe autonomic dysfunction. Median (interquartile range) of modified CASS and COMPASS-31 scores were 19 (6.33) and 3 (2.5), respectively. There was a positive correlation between modified CASS and COMPASS-31 scores ( r =0.43; P =0.004). Receiver operating characteristic curve analysis confirmed that COMPASS-31 had fair accuracy for prediction of moderate to severe autonomic dysfunction (area under the curve, 0.74; 95% confidence interval, 0.64-0.82; P =0.009). A cut-off of 30 for total COMPASS-31 score had a sensitivity of 52.2% and specificity of 89.5% to detect moderate to severe autonomic dysfunction, with positive and negative predictive values of 85.7% and 60.7%, respectively.

CONCLUSION

Patients with cervical/upper thoracic compressive myelopathy had varying degrees of autonomic dysfunction based on the modified CASS. There was a positive correlation between the modified CASS and COMPASS-31 questionnaire. A COMPASS-31 score of >30 30 could be utilized to predict moderate to severe autonomic dysfunction in patients with compressive myelopathy.

Sensitization of Hoffmann's sign in response to a reverse Lhermitte's sign: a case report

BACKGROUND

Neurologic clustering of findings is recommended with Cervical Spondylotic Myelopathy (CSM). Hoffmann's Sign and Reverse Lhermitte's Sign have been associated with CSM, which, however, have not been discussed as the only objective findings that may cause clinical uncertainty.

CASE DESCRIPTION

This case report describes how sensitizing Hoffmann's Sign following a Reverse Lhermitte's Sign guided reasoning, with a 66-year-old male presenting with a right lumbar radiculopathy diagnosis. Local lumbar symptoms and impairments were identified, however, a Reverse Lhermitte's Sign with cervical extension was the only finding that reproduced right lower extremity (LE) pain. Hoffmann's Sign, the only abnormal neurologic finding, became exaggerated when performed in cervical extension. Concern of an early presenting CSM accounting for right LE pain was considered. A neurosurgical consultation was initiated with concurrent guideline-based lumbar spine treatment and continued monitoring of neurologic status.

OUTCOMES

Seven weeks after evaluation, sudden worsening of right LE symptoms, hand numbness, ataxia, and grip weakness occurred. Cervical magnetic resonance imaging demonstrated C3-6 cord compression. A multi-level cervical decompression surgery was performed.

DISCUSSION

Using a sensitized Hoffmann's Sign-in response to a Reverse Lhermitte's Sign aided differential diagnosis of an early presenting CSM with reports of LE pain. The diagnostic utility of a sensitized Hoffmann's Sign is unknown.

Bladder and Bowel Dysfunction due to a Spontaneous Spinal Epidural Hematoma Without Paraplegia: A Case Report

CASE

A 44-year-old man developed urinary retention due to a spontaneous spinal epidural hematoma (SSEH) at the cervicothoracic junction, without paraplegia. Symptoms improved with surgical treatment.

CONCLUSION

SSEH is rare and causes acute neck or back pain and progressive paralysis. Patients with advanced myelopathy due to spinal cord compression lesion including SSEH often present with bladder and bowel disorders after exacerbation of quadriplegia. However, SSEH can cause predominant bladder and bowel disorders without paraplegia or quadriplegia. Physicians should consider that there can be a manifestation of myelopathy with bladder and bowel dysfunction without quadriplegia.

A comparison of two different surgical procedures in the treatment of isolated spinal metastasis patients with metastatic spinal cord compression: a case-control study

OBJECTIVE

The aim of the study was to compare total en bloc spondylectomy (TES) and separation surgery with postoperative stereotactic radiosurgery (SSRS) for isolated metastatic patients with spinal cord compression by assessing recurrence-free survival (RFS), overall survival (OS), postoperative complications, and quality of life scores (QoL).

METHODS

From October 2013 to December 2020, 52 isolated spinal metastasis patients with cord compression were selected and separated into two groups based on the surgical method used (TES group, n = 26; and SSRS group, n = 26). Indexes for evaluation included postoperative Frankel grade, postoperative ECOG-PS, RFS, OS, postoperative complications, operation time, intraoperative blood loss, and QoL.

RESULTS

The average follow-up duration was 31.44 months. There was no significant difference (P > 0.05) in postoperative complications and OS between the two groups. However, a significant difference in operation time, intraoperative blood loss, postoperative ECOG-PS, RFS, and mental health domain (6 months after surgery) was found between the two groups (P < 0.05). According to The Spine Oncology Study Group Outcomes Questionnaire assessment, the total pain and physical function domains scores were also elevated after surgery in both groups. However, no significant difference was observed between groups A and B (p = 0.450 and 0.446, respectively).

CONCLUSIONS

TES and SSRS were efficient methods for treating solitary spinal metastasis patients with metastatic spinal cord compression. Better local tumor control and mental health were found in the TES group, and most patients felt as if they were free of spinal tumors. Compared with TES, the SSRS caused less operation-related trauma. However, there was no significant difference in OS between the two groups.

Unusual Clinical Presentation of Hodgkin Lymphoma in a Child: Both Spinal Cord Compression and Hydronephrosis

BACKGROUND

Hodgkin lymphoma (HL) is predominantly a nodal disease with extranodal presentation being uncommon. Presentation with neurological symptoms is not uncommon in adult patients with HL. Subdiaphragmatic involvements are less common especially in childhood. In the literature, there has been no case which presented with both spinal cord compression and bilateral hydronephrosis in pediatric patients with HL.

OBSERVATION

We report a 9-year-old boy diagnosed with HL who presented with bilateral hydronephrosis and epidural involvement.

CONCLUSION

Differential diagnosis of abdominal mass in patients presenting with spinal cord compression and/or hydronephrosis should include HL. Retrograde J ureteral stenting is the treatment of choice for malignant ureteral obstruction.

The role of CGRP receptor antagonist (CGRP8-37) and Endomorphin-1 combination therapy on neuropathic pain alleviation and expression of Sigma-1 receptors and antioxidants in rats

BACKGROUND

Spinal cord injury is one of the most common causes of neuropathic pain which is not responsive to common treatments. Owing to the adverse effects of drugs, it seems that the use of Calcitonin Gene-Related Protein (CGRP) receptor antagonist or Morphine and their combination could be an appropriate strategy for pain alleviation.

METHOD

To achieve the objective, fifty six male Wistar rats were divided into seven groups. CGRP8-37 and Endomorphin-1 alone, and in combinated administration, as bolus and continues dose. Both mechanical and cold allodynia, and mechanical hyperalgesia were evaluated before and also15 and 60 min after injection to indicate the efficacy of the therapies in the acute and chronic circumstances on pain induced by spinal cord compression injury. Sigma-1 receptor experssion, oxidant and antioxidant activity after the seven days of the drug adminestration were evaluated.

RESULT

The results showed that Endomorphin-1and CGRP8-37 injections were able to reduce neuropathic pain after spinal cord compression injury. Compared to Endomorphin-1, or CGRP8-37 monotherapy, combination therapy did not show more attenuating effects on the pain threshold. Compared to the continous administration of Endomorphin-1 alone, and CGRP8-37 alone, the continous combination therapy did not reduce the pain further. Molecular studies disclosed the increased expression of the Sigma1 receptor, in the spinal cord after administration of Endomorphin-1, and CGRP8-37 alone, as well as combination therapy. Although, an increase in GPx and SOD activity, and decrease in MDA activity was observed in the combination therapy.

CONCLUSION

Our results demonstrate that either Endomorphin-1 or CGRP receptor antagonist is able to decrease the neuropathic pain after SCI but combination therapy by a CGRP receptor antagonist and Endomorphin-1 did not make any further reduction in pain sensation.

Dynamics of spinal cord compression with different patterns of thoracolumbar burst fractures: Numerical simulations using finite element modelling

BACKGROUND

In thoracolumbar burst fractures, spinal cord primary injury involves a direct impact and energy transfer from bone fragments to the spinal cord. Unfortunately, imaging studies performed after the injury only depict the residual bone fragments position and pattern of spinal cord compression, with little insight on the dynamics involved during traumas. Knowledge of underlying mechanisms could be helpful in determining the severity of the primary injury, hence the extent of spinal cord damage and associated potential for recovery. Finite element models are often used to study dynamic processes, but have never been used specifically to simulate different severities of thoracolumbar burst fractures.

METHODS

Previously developed thoracolumbar spine and spinal cord finite element models were used and further validated, and representative vertebral fragments were modelled. A full factorial design was used to investigate the effects of comminution of the superior fragment, presence of an inferior fragment, fragments rotation and velocity, on maximum Von Mises stress and strain, maximum major strain, and pressure in the spinal cord.

FINDINGS

Fragment velocity clearly was the most influential factor. Fragments rotation and presence of an inferior fragment increased pressure, but rotation decreased both strains outputs. Although significant for both strains outputs, comminution of the superior fragment isn't estimated to influence outputs.

INTERPRETATION

This study is the first, to the authors' knowledge, to examine a detailed spinal cord model impacted in situ by fragments from burst fractures. This numeric model could be used in the future to comprehensively link traumatic events or imaging study characteristics to known spinal cord injuries severity and potential for recovery.

Human recombinant erythropoietin improves motor function in rats with spinal cord compression-induced cervical myelopathy

Objective

Erythropoietin (EPO) is a clinically available hematopoietic cytokine. EPO has shown beneficial effects in the context of spinal cord injury and other neurological conditions. The aim of this study was to evaluate the effect of EPO on a rat model of spinal cord compression-induced cervical myelopathy and to explore the possibility of its use as a pharmacological treatment.

Methods

To develop the compression-induced cervical myelopathy model, an expandable polymer was implanted under the C5-C6 laminae of rats. EPO administration was started 8 weeks after implantation of a polymer. Motor function of rotarod performance and grip strength was measured after surgery, and motor neurons were evaluated with H-E, NeuN and choline acetyltransferase staining. Apoptotic cell death was assessed with TUNEL and Caspase-3 staining. The 5HT, GAP-43 and synaptophysin were evaluated to investigate the protection and plasticity of axons. Amyloid beta precursor protein (APP) was assessed to evaluate axonal injury.

To assess transfer of EPO into spinal cord tissue, the EPO levels in spinal cord tissue were measured with an ELISA for each group after subcutaneous injection of EPO.

Results

High-dose EPO maintained motor function in the compression groups. EPO significantly prevented the loss of motor neurons and significantly decreased neuronal apoptotic cells. Expression of 5HT and synaptophysin was significantly preserved in the EPO group. APP expression was partly reduced in the EPO group. The EPO levels in spinal cord tissue were significantly higher in the high-dose EPO group than other groups.

Conclusion

EPO improved motor function in rats with compression-induced cervical myelopathy. EPO suppressed neuronal cell apoptosis, protected motor neurons, and induced axonal protection and plasticity. The neuroprotective effects were produced following transfer of EPO into the spinal cord tissue. These findings suggest that EPO has high potential as a treatment for degenerative cervical myelopathy.

Role of macrophages and activated microglia in neuropathic pain associated with chronic progressive spinal cord compression

Neuropathic pain (NeP) is commonly encountered in patients with diseases associated with spinal cord damage (e.g., spinal cord injury (SCI) and compressive myelopathy). Recent studies described persistent glial activation and neuronal hyperactivity in SCI, but the pathomechanisms of NeP in chronic compression of the spinal cord remains elusive. The purpose of the present study was to determine the roles of microglia and infiltrating macrophages in NeP. The study was conducted in chimeric spinal hyperostotic mice (ttw/ttw), characterized by chronic progressive compression of the spinal cord as a suitable model of human compressive myelopathy. The severity of spinal cord compression correlated with proportion of activated microglia and hematogenous macrophages. Spinal cord compression was associated with overexpression of mitogen-activated protein kinases (MAPKs) in infiltrating macrophages and reversible blood-spinal cord barrier (BSCB) disruption in the dorsal horns. Our results suggested that chronic neuropathic pain in long-term spinal cord compression correlates with infiltrating macrophages, activated microglial cells and the associated damage of BSCB, together with overexpression of p-38 MAPK and p-ERK1/2 in these cells. Our findings are potentially useful for the design of new therapies to alleviate chronic neuropathic pain associated with compressive myelopathy.

[Cervical Myelopathy Caused by Chronic and Intermittent Cord Compression by Tumors upon Neck Rotation:A Case Report]

A 35-year-old man with neurofibromatosis type I presented with right arm weakness and gait disturbance that had developed gradually. MR imaging revealed bilateral intra-and extradural tumors at the C1-2 level. Although the adjacent spinal cord was narrowed, there was no evident contact between the tumors and the spinal cord. Computed tomography myelography revealed that the tumors compressed the cord only during neck rotation. The tumors were resected to make an abundant subdural space around the affected cord. The patient's neurological symptoms improved postoperatively. Because contact between the masses and spinal cord only occurred upon neck rotation, we believe it is important to consider the possibility of intermittent compression, termed dynamic rotational canal stenosis, in patients with masses at the C1-2 level, even when such masses are not seen to be in contact with the cervical cord on routine radiological examination.

Spontaneous spinal epidural hematoma mimicking Guillain-Barre Syndrome

BACKGROUND

The initial symptoms of Guillain-Barre Syndrome (GBS) can be similar to a case of spontaneous spinal epidural hematoma (SSEH) located at the cervicothoracic junction. Therefore, SSEH may be misdiagnosed as GBS.

CASE REPORT

A previously healthy 6-year-old girl presented with a 2-day history of progressive pain in the lower extremities and an inability to walk. On initial evaluation, she was completely paraparetic in the lower extremities. Deep tendon reflexes were absent in the lower extremities, and Babinski reflexes were positive on both sides. She exhibited reduced response to light touch and pinprick with a sensory level below T10, and experienced difficulty during urination. However, the strength, sensation and flexion of upper extremities were normal. Because her presentation and examinations were consistent with GBS, we initiated intravenous immunoglobulin therapy. The next day, she also developed pain and muscle weakness of the right upper extremity. Three days after admission, respiratory depression progressed rapidly. Spinal MRI showed a mass extending from the level of C7-T3, with spinal cord compression. The patient underwent an emergency laminectomy with evacuation of hematoma, and was diagnosed with SSEH. Sixty days after admission, she was transferred to the rehabilitation hospital with severe neurologic sequelae of paralysis in both legs.

CONCLUSION

SSEH might have severe consequences, including neurologic deficits and risk of death. This case report serves to raise the awareness of SSEH that mimics the initial presentation of GBS.

TGN-020 alleviates edema and inhibits astrocyte activation and glial scar formation after spinal cord compression injury in rats

AIMS

Identifying drugs that inhibit edema and glial scar formation and increase neuronal survival is crucial to improving outcomes after spinal cord injury (SCI). Here, we used 2-(nicotinamide)-1,3,4-thiadiazole (TGN-020), a potent selective inhibitor of aquaporin 4 (AQP4), to investigate the effects of TGN-020 on SCI in Sprague-Dawley rats.

MAIN METHODS

We compressed the spinal cord at T10 using a sterile impounder (35 g, 5 min), to induce moderate injury. TGN-020 (100 mg/kg) or an equal volume of 10% dimethyl sulfoxide was then administered via intraperitoneal injection. Neurological function was evaluated using the Basso-Beattie-Bresnahan open-field locomotor scale 1, 3, 7, 14, 21, and 28 days after SCI. The degree of edema was assessed via determination of the precise spinal cord water content 3 days after SCI. Expression levels of AQP4, glial fibrillary acidic protein (GFAP), proliferating cell nuclear antigen (PCNA), and growth-associated protein-43 (GAP-43) were determined via western blotting and immunofluorescence staining 3 days after SCI and 4 weeks after SCI. Numbers of surviving neurons and glial scar sizes were determined using Nissl and hematoxylin-eosin staining, respectively.

KEY FINDINGS

Our results showed that TGN-020 promoted functional recovery at days 3, 7, 14, 21, and 28, as well as reduced the degree of edema and inhibited the expression of AQP4, GFAP, PCNA at days 3 after SCI. Furthermore, observations 4 weeks after SCI revealed that TGN-020 inhibited the glial scar formation and upregulated GAP-43 expression.

SIGNIFICANCE

TGN-020 can alleviate spinal cord edema, inhibit glial scar formation, and promote axonal regeneration, conferring beneficial effects on recovery in rats.

[Reversible Paraplegia - Favorable Outcome After Delayed Diagnosis]

Reversible Paraplegia - Favorable Outcome After Delayed Diagnosis Abstract. A 74-year-old woman was referred for progressive gait disturbances. On presentation, she had a complete paraplegia (wheelchair-bound for 19 months) and bladder sphincter dyssynergia with sensory sacral sparing. Magnetic resonance imaging studies revealed a 24 × 13 × 17 mm intradural mass with compression of the spinal cord and myelomalacia between C6 and Th1. We performed unilateral laminectomies of C6-Th1 and microsurgical resection of a meningioma. Under intensive rehabilitation, the patient regained independent walking ability and recovery of bladder function and continence within six months postoperatively.

Chronic posterior atlantoaxial subluxation associated with os odontoideum: a rare condition. A case report and literature review

Introduction

Os odontoideum is a rare cervical lesion. This unusual condition is sometimes associated with atlantoaxial subluxation, which is mostly anterior subluxation. Posterior atlantoaxial subluxation due to os odontoideum is extremely rare.

Case presentation

We report an unusual case of a 60-year-old Thai female, who was diagnosed as having chronic posterior atlantoaxial subluxation associated with os odontoideum with progressive myelopathy. The patient underwent posterior arch of C1 laminectomy and an occipito-C3 fusion using an occipital plate, C2 pedicle screws, C3 lateral mass screws and autologous iliac crest strut bone graft arthrodesis. During three years of follow-up, she was clinically significantly improved and postoperative radiographs showed a solid osseous fusion without loss of correction or implant failure.

Discussion

Chronic posterior atlantoaxial subluxation associated with os odontoideum is rare. This condition can cause occipital-cervical pain, myelopathy, intracranial symptoms, or death. Surgical decompression and stabilization is the treatment of choice. Principles of treatment are to prevent sudden death from neurological compromise, improve neurological status, stabilize the cervical spine, and improve quality of life. Surgical options include atlantoaxial fusion, occipito-C2 fusion, and occipito-C3 fusion. Decision making depends on the location of spinal cord compression, area for arthrodesis, and bone quality.

Titanium mesh bone grafting combined with pedicle screw internal fixation for treatment of Ku[Combining Diaeresis]mmell disease with cord compression: A case report and literature review

RATIONALE

In 1891, Dr. Hermann Kümmell, a German surgeon, described a clinical entity characterized by the development of progressive painful kyphosis following an asymptomatic period of months or years after a minor spinal trauma, leading to a gradual collapse of the vertebra and dynamic instability, ultimately progressing to kyphosis with prolonged back pain and/or paraparesis. To date, the main pathologic eliciting event remains unclear, and no standard treatment or single effective treatment are available for Kümmell disease.

PATIENT CONCERNS

A 74-year-old woman presented with severe back pain and numbness of both legs for approximately 2 months.

DIAGNOSES

According to the clinical symptoms and imaging examinations, the patient was diagnosed with stage III Kümmell disease.

INTERVENTIONS

The patient underwent titanium mesh bone grafting combined with pedicle screw internal fixation.

OUTCOMES

Postoperative kyphosis was corrected, and the vertebra was reconstructed.

LESSONS

Kümmell disease is not a rare complication of osteoporotic vertebral compression fractures, and treatment of each patient must be individualized. The application of titanium mesh bone grafting combined with pedicle screw internal fixation is an effective treatment option for stage III Kümmell disease.

A rare, acute neurologic deterioration associated with the overactive autoimmune response of ankylosing spondylitis after cervical laminoplasty: A case report

RATIONALE

We report a rare, acute neurological deterioration after cervical laminoplasty due to post-decompression spinal cord edema associated with ankylosing spondylitis in a 52-year old male patient. The patient was diagnosed with cervical spondylotic myelopathy due to ossification of the posterior longitudinal ligament which was complicated by ankylosing spondylitis. A cervical laminoplasty was performed, adversely resulting in paraparesis and loss of tactile sense. An emergency CT scan following the first laminoplasty revealed that the spinal cord compression due to spinal cord swelling and limited-expansion in cervical canal space. The abnormal pathological state of ankylosing spondylitis may have aggravated spinal cord re-perfusion and increased edema after decompression.

PATIENT CONCERNS

Paraparesis and loss of tactile sense after the surgery immediately.

DIAGNOSES

Acute neurological deterioration after cervical laminoplasty.

INTERVENTIONS

A second emergency surgery was performed to remove the C2-C5 laminae.

OUTCOMES

Six months later, the patient had experienced slight improvement in neurological function.

LESSONS

Abnormal spinal cord immune inflammatory reaction associated with ankylosing spondylitis and limited decompression may lead to acute neurological deterioration. The potential overactive inflammatory response following surgery in the patients with autoimmune rheumatoid disease should be carefully considered in spinal surgery. Timely diagnosis and treatment may benefit these patients.

Metastatic epidural spinal cord compression: does timing of surgery influence the chance of neurological recovery? An observational case-control study

PURPOSE

Metastatic epidural spinal cord compression (MESCC) is radiologically defined as an epidural metastatic lesion causing the displacement of the spinal cord from its normal position in the vertebral canal. The purpose of this paper is the evaluation of the influence of timing of surgery on the chance of neurological recovery.

METHODS

This is a retrospective observational case-control study performed on patients with MESCC from solid tumors surgically treated at our institute from January 2010 to December 2016. Patients included were divided in two groups depending on surgery that was performed within or after 24 h the admission to the hospital. Neurological status was assessed with American Spine Injury Association (ASIA) Impairment Scale.

RESULTS

No statistically significant difference was observed in the variation of ASIA if surgery is performed within or after 24 h from the admission to the hospital. A statistically significant difference was observed after surgery in each group in the improvement of neurological status. A statistically significant difference was reported in the early post-operative complications in patients surgically treated within 24 h.

CONCLUSION

MESCC management is challenge for spine surgeons and may represent an oncologic emergency and if not promptly diagnosed can lead to a permanent neurological damage. According to this study, there is no difference in the chance of neurological recovery if surgery is performed within or after 24 h the admission to hospital, but there is a greater rate of early post-operative complications when surgery is performed within 24 h from the admission to the hospital.

Brachioradial Pruritus and Notalgia Paraesthetica: A Comparative Observational Study of Clinical Presentation and Morphological Pathologies

Brachioradial pruritus (BRP) and notalgia paraesthetica (NP) represent 2 of the most common neuropathic itch syndromes. A total of 58 consecutive patients presenting at the Center for Chronic Pruritus, University Hospital Münster, were analysed with regard to clinical presentation, anatomical and morphological pathologies, impairment in quality of life, and response to treatment with topical capsaicin. Patients with BRP reported stinging and burning more often than those with NP. In the BRP group structural magnetic resonance imaging abnormalities more frequently correlated with localization of the symptoms compared with in patients with NP. In addition, intraepidermal nerve fibre density was decreased in lesional skin in patients with BRP, but not in those with NP, confirming the neuropathic origin in BRP. Topical capsaicin resulted in a significantly higher alleviation of itch and pain intensity and improvement in quality of life in patients with BRP compared with those with NP, which may reflect clinical and aetiological differences between the conditions.

Managing patients with oncologic complications in the emergency department

As the prevalence of cancer continues to increase in the general population and improvements in cancer treatment prolong survival, the incidence of patients presenting to the emergency department with oncologic complications will, similarly, continue to rise. This issue reviews 3 of the more common presentations of oncology patients to the emergency department: metastatic spinal cord compression, tumor lysis syndrome, and febrile neutropenia. Signs and symptoms of these conditions can be varied and nonspecific, and may be related to the malignancy itself or to an adverse effect of the cancer treatment. Timely evidence-based decisions in the emergency department regarding diagnostic testing, medications, and arrangement of disposition and oncology follow-up can significantly improve a cancer patient's quality of life.

Sleep Disturbances in 22q11.2 Deletion Syndrome: A Case with Obstructive and Central Sleep Apnea

The 22q11.2 deletion syndrome is characterized by wide phenotypic variability, frequently involving characteristic craniofacial features, cardiac malformations, and learning difficulties. Skeletal anomalies are also common and include an obtuse angle of the cranial base, retrognathia, and cervical spine abnormalities. Despite these anomalies, sleep-disturbed breathing is not reported frequently in patients with 22q11.2 deletion syndrome. We describe a patient with an obstructive sleep disturbance that was successfully treated with a tonsillectomy followed by mandibular distraction osteogenesis. She also had central sleep apnea, initially attributed to spinal cord impingement from cervical instability. Posterior cervical fusion was associated with a decrease in the number of central apneic events.

High-precision radiotherapy of motor deficits due to metastatic spinal cord compression (PRE-MODE): a multicenter phase 2 study

BACKGROUND

For metastatic spinal cord compression (MSCC), conventional radiotherapy with 10 × 3 Gy in 2 weeks results in better local progression-free survival (LPFS) than 5 × 4 Gy in 1 week. Since patients with MSCC are often significantly impaired, an overall treatment time of 1 week would be preferable if resulting in similar outcomes as longer programs. This may be achieved with 5 × 5 Gy in 1 week, since the biologically effective dose is similar to 10 × 3 Gy. It can be expected that 5 × 5 Gy (like 10 × 3) Gy results in better LPFS than 5 × 4 Gy in 1 week.

METHODS/DESIGN

This phase 2 study investigates LPFS after high-precision RT with 5 × 5 Gy in 1 week. LPFS is defined as freedom from both progression of motor deficits during RT and new or progressive motor deficits dur to an in-field recurrence of MSCC following RT. Considering the tolerance dose of the spinal cord, 5 × 5 Gy can be safely administered with high-precision radiotherapy such as volumetric modulated arc therapy (VMAT) or stereotactic body radiotherapy (SBRT). Maximum dose to the spinal cord should not exceed 101.5% of the prescribed dose to keep the risk of radiation myelopathy below 0.03%. Primary endpoint is LPFS at 6 months following radiotherapy; secondary endpoints include motor function/ability to walk, sensory function, sphincter dysfunction, LPFS directly and 1 and 3 months following radiotherapy, overall survival, pain relief, quality of life and toxicity. Follow-up visits will be performed directly and at 1, 3 and 6 months following radiotherapy. After completion of this phase 2 study, patients will be compared to a historical control group receiving conventional radiotherapy with 5 × 4 Gy in 1 week. Forty-four patients will be included assuming 5 × 5 Gy will provide the same benefit in LPFS when compared to 5 × 4 Gy as reported for 10 × 3 Gy.

DISCUSSION

If superiority regarding LPFS is shown for high-precision radiotherapy with 5 × 5 Gy when compared to conventional radiotherapy with 5 × 4 Gy, patients with MSCC would benefit from 5 × 5 Gy, since high LPFS rates could be achieved with 1 week of radiotherapy instead of 2 weeks (10 × 3 Gy).

TRIAL REGISTRATION

clinicaltrials.gov NCT03070431 . Registered 27 February 2017.

Vascular spinal cord obstruction associated with superior vena cava syndrome: A case report and literature review

RATIONALE

Superior vena cava syndrome (SVCS) is the obstruction of blood flow through the SVC, causing complete or partial blockade of the collateral circulation of returning venous blood. SVCS is frequently presented with facial, neck, trunk, and upper limbs swelling and so on. However, to the best of our knowledge, the obstruction of the venous return in the spinal veins is rarely a manifestation of SVCS.

PATIENT CONCERNS

We presented a rare case of a 52-year-old male patient with 2-month history of progressive right upper limb numbness and swelling and 10-day history of extremities malfunctioning. Cervical magnetic resonance imaging (MRI) detected obstruction of the spinal venous return. Lung computed tomography (CT) revealed lesions in the esophagus, which indicated esophageal cancer with mediastinal lymph nodes metastasis and signified SVCS.

DIAGNOSES

With the results of laboratory findings, cervical MRI, lung CT findings, and physical examination, the patient was diagnosed with SVCS manifesting as spinal vein obstruction.

INTERVENTIONS AND OUTCOMES

The family abandoned further treatment, and the patient passed away 2 months after discharge.

LESSONS

The case indicates that SVCS can induce systemic and spinal cord diseases affecting the venous return. Further studies are necessary to reveal the mechanism for SVCS inducing spinal veins obstruction and to explore whether SVCS patients with and without vascular spinal cord obstruction have different prognoses.

Less Is More: Efficacy of Rapid 3D-T2 SPACE in ED Patients with Acute Atypical Low Back Pain

RATIONALE AND OBJECTIVES

Emergency department (ED) patients with acute low back pain (LBP) may present with ambiguous clinical findings that pose diagnostic challenges to exclude cauda equina syndrome (CES). As a proof of concept, we aimed to determine the efficacy of a rapid lumbar spine (LS) magnetic resonance imaging (MRI) screening protocol consisting of a single 3D-T2 SPACE FS (3D-T2 Sampling Perfection with Application optimized Contrasts using different flip angle Evolution fat saturated) sequence relative to conventional LS MRI to exclude emergently treatable pathologies in this complex patient population.

MATERIALS AND METHODS

LS MRI protocol including a sagittal 3D-T2 SPACE FS pulse sequence was added to the routine for ED patients presenting with acute atypical LBP over a 12-month period. Imaging findings were categorically scored on the 3D-T2 SPACE FS sequence and separately on the reference standard conventional LS MRI sequences. Patients' symptoms were obtained from review of the electronic medical record. Descriptive test statistics were performed.

RESULTS

Of the 206 ED patients who obtained MRI for acute atypical LBP, 118 (43.3 ± 13.5 years of age; 61 female) were included. Specific pathologies detected on reference standard conventional MRI included disc herniation (n = 30), acute fracture (n = 3), synovial cyst (n = 3), epidural hematoma (n = 2), cerebrospinal fluid leak (n = 1), and leptomeningeal metastases (n = 1), and on multiple occasions these pathologies resulted in nerve root impingement (n = 36), severe spinal canal stenosis (n = 13), cord/conus compression (n = 2), and cord signal abnormality (n = 2). The 3D-T2 SPACE FS sequence was an effective screen for fracture (sensitivity [sens] = 100%, specificity [spec] = 100%), cord signal abnormality (sens = 100%, spec = 99%), and severe spinal canal stenosis (sens = 100%, spec = 96%), and identified cord compression not seen on reference standard. Motion artifact was not seen on the 3D-T2 SPACE FS but noted on 8.5% of conventional LS MRI.

CONCLUSIONS

The 3D-T2 SPACE FS sequence MRI is a rapid, effective screen for emergently actionable pathologies that might be a cause of CES in ED patients presenting with acute atypical LBP. As this abbreviated, highly sensitive sequence requires a fraction of the acquisition time of conventional LS MRI, it has the potential of contributing to increased efficiencies in the radiology department and improved ED throughput.

Chronic administration of [Pyr1] apelin-13 attenuates neuropathic pain after compression spinal cord injury in rats

Apelin is an endogenous ligand for apelin receptor (APJ) with analgesic effect on visceral, analgesic and proanalgesic influences on acute pains in animal models. The purpose of this study was to determine the possible analgesic effects of [Pyr¹] apelin-13 on chronic pain after spinal cord injury (SCI) in rats. Animals were randomly divided into three major groups as intact, sham and SCI. The SCI group randomly allocated to four subgroups as no treatment, vehicle-treatment (normal saline: 10μl, intrathecally) and two subgroups with intrathecal injection (i.t) of 1μg and 5μg of [Pyr¹] apelin-13. After laminectomy at T6-T8 level, spinal cord compression injury was induced using an aneurysm clip. Vehicle or [Pyr¹] apelin-13 injected from day1 post SCI and continued for a week on a daily basis. Pain behaviors and locomotor activity were monitored up to 8weeks. At the end of the experiments, intracardial paraformaldehyde perfusion was made under deep anesthesia in some animals for histological and immunohistochemistry evaluations. Western blot technique was also done to detect caspase-3 in fresh spinal cord tissues. SCI decreased nociceptive thresholds and locomotor scores. Administration of [Pyr¹] apelin-13 (1μg and 5μg) improved locomotor activity and reduced pain symptoms, cavity size and caspase-3 levels. Results showed long-term beneficial effects of [Pyr¹] apelin-13 on neuropathic pain and locomotion. Therefore, we may suggest [Pyr¹] apelin-13 as a new option for further neuropathic pain research and a suitable candidate for ensuing clinical trials in spinal cord injury arena.

An Autopsy Case of Respiratory Failure Induced by Repetitive Cervical Spinal Cord Damage due to Abnormal Movement of the Neck in Athetoid Cerebral Palsy

We herein report the clinical and autopsy findings of a 48-year-old right-handed man with athetoid cerebral palsy who suffered from cervical myelopathy due to abnormal neck movement, and who died of respiratory failure. Pathologically, the external appearance of the ventral surface of the cervical spinal cord revealed a linear indentation running obliquely at the level between the C4 and C5 segments. In the most severely compressed lesion, the gray matter was predominantly affected and severely atrophic. Microscopically, clusters of oligodendrocytes associated with thinly myelinated axons were also observed in the lateral funiculus. The latter findings are unique, and could be interpreted as regenerative and/or restorative phenomena of the central nervous system following chronic repetitive spinal cord compression.

Reported Outcome Measures in Degenerative Cervical Myelopathy: A Systematic Review

OBJECTIVE

Degenerative cervical myelopathy [DCM] is a disabling and increasingly prevalent group of diseases. Heterogeneous reporting of trial outcomes limits effective inter-study comparison and optimisation of treatment. This is recognised in many fields of healthcare research. The present study aims to assess the heterogeneity of outcome reporting in DCM as the premise for the development of a standardised reporting set.

METHODS

A systematic review of MEDLINE and EMBASE databases, registered with PROSPERO (CRD42015025497) was conducted in accordance with PRISMA guidelines. Full text articles in English, with >50 patients (prospective) or >200 patients (retrospective), reporting outcomes of DCM were eligible.

RESULTS

108 studies, assessing 23,876 patients, conducted world-wide, were identified. Reported outcome themes included function (reported by 97, 90% of studies), complications (reported by 56, 52% of studies), quality of life (reported by 31, 29% of studies), pain (reported by 29, 27% of studies) and imaging (reported by 59, 55% of studies). Only 7 (6%) studies considered all of domains in a single publication. All domains showed variability in reporting.

CONCLUSIONS

Significant heterogeneity exists in the reporting of outcomes in DCM. The development of a consensus minimum dataset will facilitate future research synthesis.

Compressive Myelopathy due to Intervertebral Disk Extrusion in a Llama (Lama Glama)

A 12-year-old intact female llama was euthanized following acute onset of spastic tetraparesis and recumbency with inability to rise. Postmortem examination revealed caudal cervical spinal cord compression due to a mass within the ventral spinal canal arising from the C6–C7 intervertebral disk space and attached to an irregularly thickened annulus fibrosis. On histopathologic examination, the mass was composed of amorphous acellular basophilic to amphophilic material admixed with irregularly arranged collagen bundles. The amorphous material was metachromatic and contained multiple small foci of markedly vacuolated round cells, characteristic of origin from the nucleus pulposus. Severe necrosis of all white matter tracts with astrocytic reaction was present in the overlying spinal cord segment. Ascending and descending Wallerian degeneration and dissecting interstitial astrogliosis were present within white matter tracts above and below the lesion, respectively. The diagnosis was compressive myelopathy due to chronic extrusion of the nucleus pulposus of the C6–C7 inter-vertebral disk. To the authors' knowledge, this is the first report of intervertebral disk disease in a camelid.

Fluorosis... causing paraplegia... mutilating life

Fluorosis is thought to be rare in Pakistan but endemic in various parts of the world, especially in India and China. In Pakistan only a few cases have been reported from Thar, Sibbi and Manga Mandi, with probability of fluorosis on MRI findings, supported by high drinking waterfluoride content. Neurological manifestations of skeletal fluorosis may vary from radiculo-myelopathy to neuropathy. A case of 26 years old female from Thul, Sindh, who presented with paraplegia, is reported here. Her MRI showed extensive classical degenerative changes throughout the spine, consistent with fluorosis, leading to cord compression at multiple levels. No such case with confirmed fluorosis has been previously reported from Pakistan.

IgG4-related spinal pachymeningitis

The aim of this study is to study the clinical, laboratory, imaging pathology, and prognosis features of IgG4-related spinal pachymeningitis. We worked with a 55-year-old man suffering from IgG4-related spinal pachymeningitis who had the most widespread lesion in his dura mater. We also review previous related studies and discuss the clinical characteristics of this rare disease. In total, eight IgG4-related spinal pachymeningitis patients have been reported in the literature since 2009. They were mostly male patients, 51.7 ± 11.9 years old on average. Cervical and thoracic vertebrae were the most common sites for lesions. The most prominent symptom was varying numbness and weakness of the limbs and/or body associated with spinal cord compression. There was one patient (1/5) with elevated serum IgG4 levels and three patients (3/3) with increased cerebrospinal fluid (CSF) IgG4 index. Positive histopathologic findings are the strongest basis for a diagnosis. All the patients with IgG4-related spinal pachymeningitis responded well to glucocorticoid therapy. IgG4-related spinal pachymeningitis is an orphan disease that mainly occurs in cervical and thoracic vertebrae. Older males are the most susceptible group. Serum IgG4 levels were consistently normal in these cases, so analysis of CSF for IgG4 production (IgG4 index) could become a useful tool. Pathological findings remain the gold standard for diagnosis. Most patients responded favorably to glucocorticoid treatment.

Positioning and spinal bracing for pain relief in metastatic spinal cord compression in adults

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 3 (Lee 2012) on patient positioning (mobilisation) and bracing for pain relief and spinal stability in adults with metastatic spinal cord compression.Many patients with metastatic spinal cord compression (MSCC) have spinal instability, but their clinician has determined that due to their advanced disease they are unsuitable for surgical internal fixation. Mobilising may be hazardous in the presence of spinal instability as further vertebral collapse can occur. Current guidance on positioning (whether a patient should be managed with bed rest or allowed to mobilise) and whether spinal bracing is helpful, is contradictory.

OBJECTIVES

To investigate the correct positioning and examine the effects of spinal bracing to relieve pain or to prevent further vertebral collapse in patients with MSCC.

SEARCH METHODS

For this update, we searched for relevant studies from February 2012 to 31 March 2015. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In Process, EMBASE, AMED, CINAHL, TRIP, SIGN, NICE, UK Clinical Research Network, National Guideline Clearinghouse and PEDro database. We also searched the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov, UK Clinical Trials Gateway (UKCTG), WHO International Clinical Trials Registry Platform (ICTRP) and Australia New Zealand Clinical Trials Registry (ANZCTR).For the original version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, CANCERLIT, NICE, SIGN, AMED, TRIP, National Guideline Clearinghouse, and PEDro database, in February 2012.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of adults with MSCC of interventions on positioning (mobilisation) and bracing.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed each possible study for inclusion and quality.

MAIN RESULTS

For the original version of the review, we screened 1611 potentially relevant studies. No studies met the inclusion criteria. Many papers identified the importance of mobilisation, but no RCTs of bed rest versus mobilisation have been undertaken. We identified no RCTs of bracing in MSCC.For this update, we identified 347 potential titles. We screened 300 titles and abstracts after removal of duplicates. We did not identify any additional studies for inclusion.

AUTHORS' CONCLUSIONS

Since publication of the original version of this review, no new studies were found and our conclusions remain unchanged.There is a lack of evidence-based guidance around how to correctly position and when to mobilise patients with MSCC or if spinal bracing is an effective technique for reducing pain or improving quality of life. RCTs are required in this important area.